Mohs surgeon specializes in skin-cancer treatment

Published 1:15 pm, Monday, October 15, 2012

Andrew M. Herbst, M.D., is a Mohs surgeon who specializes in dermatology at the Skin Cancer Center of Fairfield County office in Norwalk.

Hour photo / Alex von Kleydorff

Andrew M. Herbst, M.D., is a Mohs surgeon who specializes in dermatology at the Skin Cancer Center of Fairfield County office in Norwalk.

Photo: 2012 The Hour Newspapers

Mohs surgeon specializes in skin-cancer treatment

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NORWALK -- When a skin lesion, mole or bump suddenly appears, changes, or bleeds, a visit to a dermatologist is in order for visual evaluation of potential malignancy, a biopsy, and surgical excision if needed.

While dermatologists are trained in the routine removal of skin cancer, there are certain circumstances in which the specialized training in cancer surgery, pathology, and reconstruction of a Mohs surgeon are indicated.

Andrew Herbst, M.D. is one of just a handful of Mohs surgeons in southwestern Connecticut and has recently opened a new office in Norwalk.

His physician referral-based practice treats patients in which the type or location of confirmed cancer requires his evaluative and reconstructive expertise.

According to the American College of Mohs Surgery: "There are many acceptable treatment option advantages to Mohs surgery over other skin cancer treatment options that include freezing, scraping and burning, excision, and laser surgery, which all require the surgeon to estimate how extensively to treat the area around the tumor.

"There are many advantages to Mohs surgery including its high cure rate … It is especially appropriate for skin cancers that develop on areas where preserving cosmetic appearance and function are important, have recurred after previous treatment or are likely to recur, are located in scar tissue, are large, have ill-defined edges, and grow rapidly."

And Herbst said, "With Mohs we are not obligated to take an arbitrary margin of normal skin. The cure rate is higher with Mohs and reconstruction typically occurs on the same day."

Mohs surgery treats skin cancer through a highly specialized and precise technique that removes cancer one tissue layer at a time. The tissue is microscopically examined under a microscope until cancer-free tissue around the tumor is reached.

The Mohs in-office procedure consists of a local numbing agent applied to the affected area. The tumor is removed along with a thin layer of surrounding tissue, and a temporary bandage is applied. While the patient waits for about an hour in a comfortable waiting room complete with views of the Norwalk River, the tissue is prepared and put on slides to be examined under a microscope by Herbst. If there is evidence of cancer, another layer of tissue is removed from the area where it was detected.

"The slide is analyzed, and if the tissue is clear we bring the patient back in and stitch them," Herbst said.

While many repairs are stitched in a straight line, some reconstruction requires more advanced techniques such as a surgical flap or skin graft.

Herbst's advanced fellowship training at the Dermatologic SurgiCenter in Philadelphia consisted of one year of concentration on Mohs microscopic surgery and reconstructive training.

"During my fellowship, all I did for that year was Mohs surgery. Training consisted of reconstruction of surgical sites with flaps and grafts," said Herbst, who estimated he's performed more than 10,000 Mohs procedures in the last 11 years.

Mohs surgery was first developed in the 1930s by Dr. Frederic Mohs, professor of surgery at the University of Wisconsin, who recognized that tumor cells grow downward and outward under the skin and are not visible to the naked eye, but can be seen under a microscope.

"Throughout all technical improvements in devises and refinements of technique, the focal point-the color-coded mapping of excised specimens and their thorough microscopic examination-remains the defining part of the Mohs Micrographic Surgery to this day," according to the ACMS.

Mohs surgery is indicated for treatment of basal cell and squamous cell carcinoma.

"Basal cells typically don't spread, but they are locally destructive," Herbst said. "They don't affect the liver, lungs, lymph nodes. But they will eat away at the skin. Squamous cells can become aggressive and spread to lymph nodes."

"Melanomas are potentially the most aggressive and are typically not amenable for Mohs," Herbst said. "Where tumors spread contiguously, melanoma can skip areas, it can be insidious. People also may think that if a lesion isn't raised, it couldn't be melanoma. The fact of the matter is, it can be completely flat and quite dangerous."

Herbst offered common sense reminders about skin cancer in general:

"If there is anything new or changes in the skin, bleeding, or if there's a family history of skin cancer, or a history of sunburn, the recommendation is to see a dermatologist," Herbst said. "While the risk of skin cancer increases with age, I've seen it in young people. I've had a handful of patients as young as their twenties."

Seeing his role as a problem-solver, Herbst commented on his specialty.

"I enjoy what I'm doing. I'm presented with a problem to solve and Mohs combines surgery and pathology, which are two of my passions," Herbst said.